Early adopters and lemmings: look before you leap into electronic records.

Late one evening as the sun was beginning to set, I heard the thunderous footfalls of what seemed like thousands of people outside my home. I ran to the window and lo and behold, thousands of physicians and practice administrators were marching, almost running, down the street along with many of my colleagues.

"Joe," I shouted, "Where is everyone going?"

"We're buying EMR systems," Joe shouted back.

"Why?" I asked

"They will improve quality and save money," he responded.

"How much and for whom?" I called back.

"I don't know, but a thousand lemmings can't be wrong. You better hurry," Joe replied.

And as the sun slowly set and I looked toward the horizon, all I could see were masses of lemmings running towards the cliffs by the sea.

Moving from a paper medical record system--that began 3,000 years ago in ancient Egypt by healers recording their notes on papyrus--to an electronic medical record (EMR) is an important step in the evolution of medical care.

However, it is important not only to understand how far the technology has come, but where it is going. An EMR by itself is not the panacea, even though it's highly touted by the federal government, states and national and local medical societies.

Although accessibility to clinical data is important, the areas that show the greatest promise of providing discernable benefits in the near future are:

* Online computerized provider order entry (CPOE)

* Clinical decision support tools (CDS)

EMR systems by themselves are acknowledged to be repositories for information previously captured in paper records. They provide the opportunity to deliver better care if the information they contain can be accessed and utilized when and where it is needed.

The CDS and CPOE tools being developed are where significant improvements in quality and savings are expected.

CPOE

Blackford Middleton, MD, MPH, MSc, chairman of the Center for Information Technology Leadership in Wellesley, Mass., estimates that for the average ambulatory care provider with a panel of 2,000 patients, using advanced CPOE tools will provide $28,000 in saving a year for the health system.

For CPOE tools to be effective, they need to connect to pharmacies, laboratories, radiology and other providers, so that when someone enters an order the system will:

* Confirm that the test, prescription, etc. was ordered (or advise the physician that someone else has already ordered the test or that a drug is contraindicated based on other drugs dispensed)

* Provide results of lab and other diagnostic tests

CPOE tools are provided at very low cost or even given away by many health plans, laboratories and others who benefit from their use. CPOE tools may be interfaced with EMR systems to allow physicians to simultaneously enter new orders into the CPOE and EMR databases.

However, the CPOE tools are not "integrated" into the EMR. The CPOE data are typically retained in databases at various labs, pharmacy benefit managers, etc. As a result, only the tests ordered by providers sharing the same system are retained in the EMR.

CPOE tools that are not linked to the major pharmacies, labs, etc. in the community are far less likely to eliminate duplication of services and adverse drug events.

CDS

The greatest untapped potential for EMR systems is the use of CDS tools. Although these tools may provide long-term benefits with respect to preventive health, in the short term their greatest potential benefit is to more effectively address the needs of the complex, chronically ill population.

Ten chronic care improvement pilot projects being administered by Centers for Medicare & Medicaid Services are targeted at complex diabetic and congestive heart failure (CHF) beneficiaries. Organizations awarded the contracts are required to produce a savings of approximately $850 per year per beneficiary.

Assuming 300 (15 percent) of the 2,000 patients in an internal medicine practice are Medicare patients, and the complex diabetic and CHF population targeted for the chronic care improvement pilot program constitutes 10 percent of that patient population (1.5 percent of the total practice), there should be 30 patients in the practice who--if they comply with evidence-based protocols--would produce a savings of (30 X $850=) $25,500 per year.

Assuming 34 (2 percent X 1,700) of the remaining non-Medicare patients in the practice also were complex diabetic or CHF patients, this would produce $28,900 per year in savings or a total of $54,400 in annual savings (exclusive of the additional savings derived from the use of the CPOE tools).

In response to this opportunity, a few physicians across the country are adopting EMR systems that allow them to refine, build, trade or sell their "templates" to other physicians using the same systems. As a result, we assume (although there are no large trials):

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* Disparities in medical care and medical errors in these practices are decreasing

* Use of evidence-based protocols recommended at the time of a specific visit--and the quality of care measured on what the physician does at the time of the visit--are rapidly improving

Compliance

The ultimate question, however, is not whether physicians are practicing better medicine, but whether their efforts are actually improving the health care of the patients and reducing complications and costs associated with non-compliance with evidence-based protocols.

The Crossing the Quality Chasm report by the Institute of Medicine points out that the role of physicians is not to treat the chronically ill population but to:

* Learn from the patients how well they complied with the evidence-based treatment protocols recommended at their last visit, how well they maintained their key clinical indicators with benchmarks since their last visit and any problems they encountered with compliance and complications they encountered associated with their chronic diseases

* Teach the patients the significance of any of their key clinical indicators, gaps in care, evidence-based treatment plans they should follow to achieve their goals and avoid unnecessary complications, and ways in which they may overcome obstacles to compliance

This process is exemplified at SouthEast Texas Medical Associates (SETMA), a multispecialty medical group in Beaumont, Texas where its leader, James L. Holly, MD, has used EMR and clinical decision support tools to transform the culture of both physicians and staff.

The result is a professional staff that comes to work each day to learn from and teach both themselves and their patients. Not only do the SETMA physicians use evidence-based CDS tools but more importantly, they:

* Provide their patients a report after each visit showing the key clinical indicators, exceptions and protocols to follow between visits

* Call their chronically ill patients between visits, (especially those who are non-compliant with protocols and at greatest risk for complications) despite the fact that the follow-up calls by their staff are not reimbursed

There are studies that show the use of EMR systems with CDS tools will greatly facilitate the physician's ability to address the multiple complex issues at the time of the visit and increase the physician's use of evidence-based protocols. But there are few studies with community-based physicians to determine if patient compliance between visits actually improves when physicians use these tools.

Concurrent to the evolution of CDS tools in physician practices, health plans are employing care managers as part of their disease management programs with similar tools and are also attempting to improve compliance of this same patient population.

However, due to the limitations of today's technology, and the poor communication between health plans and physicians, there is generally little or no interaction between physicians and care managers. And in the worst cases, physicians and care managers make different recommendations to the patient.

As a result, without ongoing encouragement by physicians for patients to follow-up with their care managers between visits, the percentage of patients targeted by disease management programs in which the patients effectively become engaged and improve compliance is relatively low.

Economics

Let's assume the physician can now, through the power of the EMRs and CDS and CPOE tools, change the behavior of the non-compliant patient (who has likely been non-compliant for many years). What is the economic impact on a medical practice?

Despite cheerleading by EMR vendors and a few EMR physician champions about the savings associated with adoption of EMR systems, the savings aren't instant.

"Physicians require financial incentives of $12,000-$15,000 per year for at least a three-year period to cover their cost of adoption and transformation of their practice," states a report by Connecting for Health titled "Achieving Electronic Connectivity in Healthcare--A Preliminary Roadmap from the Nation's Public and Private-Sector Healthcare Leaders." (www.markle.org)

These estimates ($12,000-$15,000 per year for the first 3 years) should cover the technical basics for a small physician practice including hardware, software and installation, but may not be sufficient to cover other essential costs including, but not limited to, implementation assistance and ongoing personnel necessary to support the application, cost of additional modules or modifications to further productive use, initial practice productivity impacts related to adoption, (productivity can be impacted by as much as 20 percent especially during the first six months of using an implemented system), high degrees of community-wide connectivity, impacts of practice paradigm shifts or the significant risk of adoption failure, the report states.

Given these costs, what is the case for adopting EMR systems today?

Motivation

It is inevitable that if we are to encourage a robust health care system in the United States in the near future there must be economic incentives to motivate each of the stakeholders (providers, health plans, employers, patients and technology companies) to develop and implement appropriate, connected health care technology.

Several efforts are under way to address the financial costs of transformation including:

* Grant funds for demonstration programs. However, the funding required to pay for the technology goes well beyond the amount the government is likely to provide.

* Pay-for-performance programs that reimburse physicians if desired outcomes for a designated patient population are achieved. However, most small practices have too few patients in the designated patient population (e.g. diabetes) with any one health plan to preclude the results being skewed by a few non-compliant patients.

* "Pay-for-use" programs are beginning to emerge with greater and greater promise. These programs are based on the premise that if physicians do what is expected, the expected outcomes will be realized. The physicians should be compensated based on documentation that appropriate care is delivered.

Incentives

Revenues and profits realized by health care technology companies are growing at 30 percent per year or more. The hot market is attracting an increasing number of competitors so players have a strong incentive to:

* Capture as much market share today as possible while profit margins are relatively high

* Differentiate themselves from the large numbers of EMR systems in the market without diminishing their value or price

Regardless of the growing number of "How to Choose an EMR System" guides and rating systems, the ultimate force that will determine which system a provider purchases will be financial incentives offered by health plans to offset the physicians' costs of acquiring the technology and transforming their practices.

Obstacles

Given the potential benefits, why aren't health plans connecting the care managers in their disease management programs to physicians using EMR systems with CDS tools? The obstacles include:

Small numbers

Assume that a health plan has 2 percent of their patients in disease management programs and the carrier covers 30 percent of the population. In a practice with 2,000 patients, this equates to 12 patients.

Although the potential dollar savings for connecting the physician practice and care managers may be substantial, given the few physicians who currently have EMR systems and the few patients a disease management program may have in any one physician practice, it is impractical for multiple carriers to build independent data exchange systems with each physician.

However, if a common data exchange system is developed to serve multiple carriers and multiple physicians using multiple EMR systems, the practicality and potential dollar savings that can be derived from each physician becomes much more significant.

And once one health plan realizes success by connecting the disease management program physician practices, competition will rapidly push others to follow.

Trust

It is challenging to convince competing health plans and technology companies to sit down at the same table and to develop a program to help physicians incentivize the transformation of medical practices even when it will ultimately serve their own self-interest.

Dr. Jean-Claude Healy, director of ehealth strategy at the World Health Organization, remains optimistic that the logjam will be broken.

"Just as technology was adopted over a short period of time by the banking industry, technology will eventually be adopted by the health care industry," he explained during a recent health care technology meeting. "First very slowly and then at a faster and faster pace until the transformation is complete."

Mitch Diamond is president and CEO of Quality Improvement Partners in Baltimore, Md. He can be reached at 443-527-2056 or [e-mail].

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RELATED ARTICLE: Pay-For-Use Plans Emerging

One pay-for-use plan is being developed by a few of the leading EMR and technology companies, health plans, employers and medical societies in the Mid-Atlantic region. It's known as Quality Improvement Partners.

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Under the pilot program, health plans and their disease management programs are being asked to:

* Analyze data provided from the data exchange

* Determine if patients being seen by physicians who refer patients to the care manager for follow-up after each visit and exchange clinical data with the care managers have better key clinical indicators and lower claims costs than patients in their disease management program being seen by other physicians

* Agree to share any savings that are realized through the program to provide a return on investment to the physicians and the data exchange

A leading third-party outsourcing technology company that does not provide EMR systems nor operate health plans or disease management programs will develop and support the data exchange between participating health plans and systems.

The EMR and technology companies are providing initial funding to pay physicians additional compensation after each visit as an inducement for using the technology and working cooperatively with the care managers. The companies are taking a risk that the use of the systems and data exchange will produce sufficient savings to recover the costs of operating the program and provide a sufficient return to attract additional investors to fund future growth.

Support is also coming from state medical societies that are endorsing the model and promoting the pilot to physicians.

Hopefully the program will determine that improved quality and savings are more than sufficient to justify the cost of the physicians adopting the technology and the cost of the data exchange.